چکیده انگلیسی

This study aims to explore the factors that explain the mental sequelae of war-related sexual violence and focuses in particular on the role of stigmatization. Drawing on a large-scale quantitative survey undertaken in the war-affected region of eastern Democratic Republic of the Congo, we analyze how stigmatization mediates the mental health impact of sexual violence on adolescent girls who were victims of rape. Twenty-two secondary schools were randomly selected out of a stratified sample in Bunia, Eastern Congo. In a cross-sectional, population-based survey, 1,305 school-going adolescent girls aged 11–23 completed self-report measures assessing war-related traumatic events, experiences of sexual violence, stigmatization, and mental health symptoms. Of the 1,305 participants, 38.2% (n = 499) reported experiences of sexual violence. Victims of sexual violence reported more war-related traumatic events and more stigmatization experiences. Several hierarchical regression analyses examined the mediating impact of stigmatization on the relationship between sexual violence and mental health outcomes, thereby controlling for sociodemographics (age, parental availability, and socioeconomic status) and war-related traumatic exposure. Our findings show that this stigmatization largely explains the mental health impact of sexual violence, in particular, on adolescent girls’ reported symptoms of depression (full mediation) and posttraumatic stress (avoidance and total PTSD: full mediation; hyperarousal: partial (40%) mediation). No evidence of mediation by stigmatization was found for symptoms of anxiety and intrusion. Stigmatization plays thus an important role in shaping the mental sequelae of sexual violence, a finding with major consequences for clinical practice.

مقدمه انگلیسی

For decades, the eastern regions of the Democratic Republic of the Congo (DRC) have been affected by war, costing the lives of over five million people (International Rescue Committee Survey, 2008), and marked by massive human rights abuses against civilians (Johnson et al., 2010). These war tactics, using civilians as targets of violence, show how organized violence often aims primarily to affect families, kinship, and community bonds and, as a result, pervasively disrupts those core social ties (Derluyn, Vindevogel, & De Haene, 2013).
In the context of the DRC, one of these weapons of war that disrupts social bonds is the excessive use of sexual violence (Bartels et al., 2010, Duroch et al., 2011, Maedl, 2011, Peterman et al., 2011 and Wakabi, 2008), with overall estimates of between 1.69 and 1.80 million Eastern Congolese women aged 15–49 years having reported histories of being raped (Peterman et al., 2011). Despite formal peace agreements, sexual violence is still highly prevalent (Maedl, 2011), with increasing reports of rape by civilian perpetrators (Bartels et al., 2010 and Duroch et al., 2011), in particular against minors (Kalisya et al., 2011). Through targeting women in communities in which female members’ social position is intricately linked to their sexual trajectories, sexual violence operates as a powerful weapon for destroying social connectedness (Derluyn et al., 2013). Indeed, the social exclusion of victims of sexual violence is highly prevalent in war-affected communities in the DRC and is documented as being associated with the pervasive stigmatization of violated girls and women (e.g., Kelly et al., 2012). Here, victims are labeled, perceived according to negative stereotypes (e.g., contaminated, defiled, of less value, and worthless), and are discriminated against within their own families and communities (Dolan, 2010 and Kelly et al., 2012).
This disruption of community ties through stigmatization also leads to the question of how pervasive stigmatization in the aftermath of sexual violence may shape mental health sequelae in victims. Previous studies have documented the impact of war-related sexual violence on victims’ mental health (Bartels et al., 2010, Johnson et al., 2008 and Johnson et al., 2010), showing a robust association between sexual violence and posttraumatic and depressive symptomatology. Furthermore, studies have equally shown how, in the aftermath of sexual violence, victims are confronted with negative social consequences invoked by sexual violence, such as negative social reactions, stigmatization, abandonment, rejection, and loss of social support networks (Campbell et al., 2001 and Filipas and Ullman, 2001). However, studies evaluating to what extent these social disruptions mediate (i.e., explain) posttraumatic and depressive mental health outcomes in victims of sexual violence in contexts of organized violence are very scarce: Only one study documented how social stigmatization explained depressive functioning in Sierra Leonean former child soldiers who were victims of rape (Betancourt, Agnew-Blais, Gilman, Williams, & Ellis, 2010). This study therefore aims at furthering an understanding of the intricate interactions between mental health outcomes and social disruption resulting from sexual violence in war-affected communities, and analyses the mediating role of stigmatization in shaping the mental health sequelae of sexual violence. Specifically, considering the paucity of research on this population, we study the extent to which stigmatization explains (i.e., mediates) the relationship between sexual violence and mental health outcomes in Eastern Congolese adolescent girls, given continuing reports of the high prevalence of sexual assaults on adolescent girls and their particularly vulnerable position in the DRC (Kalisya et al., 2011 and Kelly et al., 2010).
Methods
Participants and procedure
The study was conducted in the Ituri district of Eastern DRC, a region afflicted for decades by armed conflict (Human Rights Watch, 2003 and Médecins sans frontières, 2005). Twenty-two secondary schools from all 10 neighborhoods across the large region in and around Ituri's capital city, Bunia, were selected using stratified sampling in relation to location (rural, suburban and urban regions) and religion; no schools refused to participate. In all schools, all female pupils in the second and third grades of secondary school (The Congolese educational system consists of six years primary school followed by six years secondary school. Second to third year students of secondary school could be expected to be from 13 to 15 years old. However, prolonged conflict in Eastern Congo has affected the educational participation and attainment of Congolese youths, resulting in broad age varieties in some class groups.), where literacy and comprehension of the questionnaires could be assumed, were invited and consented to take part in the study (n = 1,305). The participants were between 11 and 23 years old. The questionnaires were administered in a six-week period in April and May 2011 during a 60- to 90-min course session while the boys of the respective classes were engaged in other activities organized by the teacher. A description of the study was provided to the participants and their written informed consent was obtained. The questionnaires were self-administered, and research assistants provided thorough and structured guidance. To promote inter-researcher reliability, extensive training (90 h) was provided to all research assistants. Questionnaires were administered in French because this is the official language in secondary schools and a pilot study showed that students preferred French questionnaires over translated Kiswahili versions. The researcher provided participants her contact information and information on local psychological support projects for those in need of further professional care. Agreements with these local services were made beforehand to guarantee adequate referral of study participants, if needed.
Ethical approval for the study was given by the Ethical Committee of the Faculty of Psychology and Educational Sciences, Ghent University.